Provider Demographics
NPI:1437159886
Name:HENDERSON, AMY HALLAL (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:HALLAL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SILVERCREST DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-7800
Mailing Address - Country:US
Mailing Address - Phone:812-948-1641
Mailing Address - Fax:812-941-0438
Practice Address - Street 1:2 SILVERCREST DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-7800
Practice Address - Country:US
Practice Address - Phone:812-948-1641
Practice Address - Fax:812-941-0438
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052944A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200403200BMedicaid
KYP00362329OtherRRMCR - NICC
IN1727118OtherCIGNA
INP00305291OtherRRMCR - NICC
000000381971OtherANTHEM - NICC
IN200403200Medicaid
IN000000235706OtherANTHEM
045019OtherSHIO - NICC
IN196290FFMedicare PIN
000000381971OtherANTHEM - NICC
KY1361997Medicare PIN
IN176160Medicare ID - Type UnspecifiedMEDICARE